Improved Data Quality, Clinical Workflows Generate eCQM Success

November 08, 2018 - To succeed with electronic clinical quality measures (eCQMs), organizations should optimize their data quality, improve data governance efforts, and enhance clinician education, according to a recent report from The Joint Commission (TJC).

The report recognized nine organizations that have leveraged eCQMs and health IT to drive quality improvement. As part of its Proven Practices Collection, TJC identified several trends that contributed to the success of these organizations, including plans to improve data quality and accuracy.

TJC found that hospitals and health systems leveraged numerous tools and strategies to enhance the quality of their data, including visual techniques.

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“Interactive dashboards and data visualizations were developed with intuitive analytic options, giving users the ability to drill down to data specifics and to see high-level summary data. This information was then used to optimize documentation,” the report stated.

Texas Health Resources of Arlington, Texas, was one organization that set out to boost its data quality with data visualization. The health system made an eCQM dashboard available to all end users in the EHR, allowing them to view accurate performance data updated weekly. The dashboard also included a feature that helped users focus on opportunities for documentation improvement.

St. Mary Medical Center in Langhorne, Pennsylvania, also implemented data visualization tools to drive quality and accuracy. The organization created a dashboard to monitor trends over time and compare retrospective data measures. Hospital leaders can access the dashboard to ensure all relevant data is accurately captured.

In addition to data quality and accuracy, entities sought to improve their data governance strategies. To do so, many health systems encouraged partnerships among different organizational groups.

“Almost all organizations noted the need for interdisciplinary teams and improved collaboration between multiple departments within an organization,” the report said.

“Many of the committees providing oversight for eCQM implementation used some combination of leadership, quality, clinical informatics, IT and clinical stakeholders to lead their efforts.”

BayCare Health System, located in Clearwater, Florida, is an example of one such organization. BayCare created a multidisciplinary team that included physicians, nurses, project managers, and health information managers.

The group compared manually abstracted data with eCQM data in a single spreadsheet and used this as a resource to detect variations in the data. The team also conducted weekly eCQM meetings, where they worked through documentation issues.

Health systems also highlighted the importance of improved clinician education and workflows in achieving eCQM success.

“Education was frequently cited as a necessity by organizations to optimally implement eCQMs. It was important for clinicians, for example, to understand elements of eCQMs so they can make better informed decisions about data flow, particularly as it relates to their clinical documentation,” The Joint Commission stated.

MedStar St. Mary’s Hospital in Leonardtown, Maryland, implemented alerts and triggers within the EHR workflow to standardize its stroke discharge documentation. St. Mary’s also decided to add an interactive view that would show clinicians all stroke-specific assessments.

To familiarize staff with these workflow changes, the organization provided leaders with a workflow outline that they could discuss and share with associates in daily huddles and meetings. Clinicians also engaged in hands-on simulation training.

And at St. Luke’s Cornwall Hospital in Newburgh, New York, computerized physician order entry (CPOE) and templates in progress notes to helped improve clinical workflows. The organization formed a team that would evaluate clinical workflows and offer guidance to providers at the point of care.

By sharing best practices from these organizations, The Joint Commission expects to help other healthcare entities succeed in their quality improvement efforts.

“The successes of these organizations are now available to all hospitals to help inform and guide their efforts to drive quality improvement,” the report concluded.

“All of the initiatives being recognized in the Proven Practices Collection are replicable and freely available for tailoring to organizations’ performance measurement and quality improvement work.”